Motivational Interviewing with

Substance Use Disorders

Elizabeth Jenkins, Ph.D.

Health Behavior Coordinator & Clinical Psychologist

Tampa VA July 2017

Does working with individuals ever feel like this?

Motivational Interviewing:

Getting Started • What challenges have you encountered

clinically when working with individuals who are homeless or at risk for homelessness?

• What are some problem situations that you see that you’d like to see change?

• What are some of the barriers to helping veterans who are abusing substances?

Considering Motivational interviewing

• Importance and Confidence for Using MI – On a scale of 0 -10, how important is it for you to

learn to apply MI in your interactions with veterans?

– On a scale of 0-10, how confident are you in your ability to utilize MI in your interactions with veterans?

0-------1-------2-------3-------4-------5-------6-------7-------8-------9-------10 Not at all Extremely

Confident Confident

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What is Motivational Interviewing?

.. a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

(Motivational Interviewing: Helping People Change. William R Miller, PhD, Stephen Rollnick, PhD. Guilford Press, Sep 2012)

People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others.

-Blaise Pascal, Pensees, #10, 1660

The Keys to Readiness

Readiness

Confidence

Importance

Motivational Interviewing and Homelessness

• MI provides a useful framework for working with individuals who are experiencing homelessness and/or struggling with substance use, mental illness, and traumatic experiences

• Within the spirit of MI is an appreciation of the challenges for changing learned behaviors, some of which may have been an important part of survival

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Origins of Motivational Interviewing

• MI started with Bill Miller • While on sabbatical in 1983, he was asked to mentor

young psychologists about behavioral treatments for alcohol problems

• Their questions about his style led him to articulate components that were not part of the behavioral therapy per se

• From that emerged a conceptual model and clinical guidelines for MI

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The Model

• Differential responses to an individual’s speech using an empathic, person-centered style

• Focus of attention: evoke and strengthen individual’s verbalized motivations for change

• Rather than confronting the lack of change, the counselor responds with empathic understanding

• Based on Miller’s observations that arguing for change tends to evoke further defenses for maintaining the status quo

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The Spirit of Motivational Interviewing

• Motivation for change is elicited from the veteran and not imposed on the veteran.

• It is the veteran’s task, not the counselors, to articulate and resolve his or her ambivalence.

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Rollnick & Miller, 1995

• Autonomy • Both implicitly and explicitly recognizing that the client will exercise

choice • Asking permission

• Collaboration • Non authoritarian, partnering style; non-judgmental • Expertise vs. expert

• Evocation • Exploring what is important to the client, their ideas, needs, values and

reasons for change; making no assumptions • Viewing clients as the experts • client speaks more than clinician

• Compassion • Actively promoting the client’s welfare • Prioritizing the client’s needs

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The Spirit of MI

Confrontation is not consistent with MI

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Common Misconceptions

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1. This person OUGHT to (or should WANT to) change.

2. Patients are either motivated or not. If not, there’s nothing we can do for them.

3. Now is the right (only?) time to change. 4. A tough approach is always best. 5. I’m the expert, so he/she should follow my advice. 6. If the person decides not to change, the

consultation has failed.

Guiding Principle of MI

Encourage the veteran to voice the argument for change rather than the

therapist

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MI Influences Change Talk

• What is “change talk”? • Study looking at persuasion with confronting vs.

reflective listening & differential reinforcement • Participants in MI condition verbalized twice as

much change talk and ½ as much resistance • MI influences change talk, and change talk predicts

behavior change

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Desire: • I want to stop smoking

Ability: • I can do this if I just get a handle on my anger

Reasons: • Getting high makes my family not want to be with me • Uncontrolled blood sugars damage all parts of my body

Need: • I need to do this so I won’t have to live in a family care home anymore • It is not fair to my kids that I don’t take care of myself

Commitment: • I will work with my therapist to get better at staying sober • I will schedule an appointment to meet with my doctor about Chantix

Activation: • I ready to go to treatment and quit for good

Taking Steps: • I went to an AA meeting last week

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Change Talk: The Ingredients of Change

• Feeling two ways about a thing • Normal part of the change process

• Common prior to habit change as well as during habit change

• A communication trap: Argue one side, person defends the other

• Defense of status quo makes change less likely

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Ambivalence

Appreciate Ambivalence Using marijuana Quitting

marijuana

Benefits

of:

Helps me sleep Helps with pain It’s not like I’m hurting anyone I feel better when I smoke

Kick this hacking cough Save money Stay out of jail Finish probation Keep my housing

Costs of:

Doctor lectures me I am broke Nasty cough Legal problems

What the hell else is there to do? My pain will be worse I will feel more anxious

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Tenets of MI: Ambivalence

• "Lack of motivation" is often ambivalence; both sides are already within the person

• If you argue for one side, an ambivalent person is likely to defend the other

• As a person defends the status quo, the likelihood of change decreases

• Resist the "righting reflex" - to take up the "good" side of the ambivalence

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Principals: The Righting Reflex What is it?

• The natural inclination we have to make it better for another person

What’s the danger? • We tell the other person what to do, how to do it, and why they

should do it without talking to them and learning what they think

• It creates resistance in that we move away from the partnering stance of MI and into the expert top down role

What to do when you find yourself doing this? • Stop and Reset • “Mrs. Smith, I realize I have been just lecturing you about the

dangers of opiate abuse without learning what you are thinking. Let me back up and hear from you, wherever you would like to start.”

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• They don’t see (denial, lack insight, etc.) • They don’t want to see • They don’t know • They don’t know how • They don’t care

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We often think The problem with people is ...

• Give them Insight - if you can just make people see, then they will change

• Give them Knowledge - if people just know enough, then they will change

• Give them Skills - if you can just teach people how to change, then they will do it

• Give them Hell - if you can just make people feel bad or afraid enough, they will change

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To Promote Change, We Often Try to…

• The veteran makes a change briefly to try to satisfy us but not for his/her own benefit and often does not continue the change

• Veteran listens politely and then proceeds to do what he/she elects to do

• Veteran protests and we push harder • No one benefits • We blame the Veteran: call him/her “not

motivated”

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What Happens?

“Righting” Reflex Ambivalence

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MI is Dancing rather than Wrestling…

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VIDEO: The Join Up with Monty Roberts: https://www.youtube.com/watch?v=9Dx91mH2voo :05 – 4:10 6:30 – 7:30

So how do we guide, nudge, collaborate with veterans to

increase the likelihood that they will engage in

behavior change?

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1. Engaging: listening to understand the dilemma using OARS

2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice

3. Evoking: selective eliciting, selective responding, selective summaries toward change talk

4. Planning: moving to a change plan and obtaining commitment

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Four MI Processes

When is it MI? Processes 1, 2, and 3 are necessary for it to be MI

Goals • Build a therapeutic relationship • Understand the client’s reality • Understand the client’s feelings, beliefs, values,

concerns (including importance and confidence) • Recognize and affirm strengths, motivation • Accept without judgment what you have learned

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Process I - Engaging

• Open-ended questions: understanding the client’s perspective and motivation, agenda setting, eliciting change talk

• Affirmation: recognizing the client efforts and strengths

• Reflection: sharing and deepening understanding, eliciting more, selectively reinforcing change talk

• Summary: understanding, eliciting more, reinforcing change talk

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Process I - Engaging: OARS

• Questions that can’t be answered with a single word (e.g., “yes,” “no,” place, date)

• Request elaboration – “Tell me more.” • Explore: needs, values, expectations, experiences,

feelings, beliefs, priorities, importance, confidence • Evocative, collaborative, honors autonomy

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OARS: Open Ended Questions

OARS: Open Ended Questions

• “What worries you about your current situation?” (disadvantages of current behavior)

• “How would you like your life to be five years from now?” (advantages of change)

• “What encourages you that you can change if you want to?” (optimism about change)

• “What would you be willing to try (intention) or what do you think you might do?”

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OARS: Affirmations • “In spite of these setbacks, you keep trying to quit” • “When you put your mind towards doing

something, you do it” • “It seems like you’re a spirited and strong person” • “You enjoy being happy with other people and

making them laugh” • “You are clearly a resourceful person to cope with

such difficulties for so long”

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• MI is built on these skills • Effortful use of listening to seek, clarify and deepen

understanding • Hypothesis testing • Creates awareness of gaps in understanding (for both

speaker and listener)

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OARS: Reflective Listening

• So, you are saying …. • It sounds like ….. • You are wondering if.... • I hear you saying…. • You are…

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OARS: Responding reflectively – Stems

• Clarify that you are getting it, understanding

• Invite the participant to respond and set the direction for the conversation

• Generate more change talk than responses to open questions

• Prevent a question and answer dance which may shift the balance from one of collaboration to one of being in charge

• Provide a tool for addressing discord (“resistance”)

• Suggested ratio: best practice = 3 reflections to 1 question

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OARS: Why Focus on Reflections?

OARS: Reflective Listening

Veteran: “I know we made all these goals about my getting into treatment, but groups are just not my thing.”

Counselor: “It’s important to find a treatment that feels like a good fit for you.”

Veteran: “I just don’t like the way my family talks to me about my drinking.” Counselor: “You have some ideas about more effective ways they could show their concern”

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OARS: How might you reflect this statement?

“I’m not an alcoholic. I know what an alcoholic looks like.”

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OARS: How might you reflect this statement?

“I am never in one place and so it’s hard to check my blood sugars when I’m supposed to.”

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OARS: How might you reflect this statement?

“Look, it’s not like I’m lazy. I just haven’t found the right job yet. ”

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“What is the big, freaking deal about marijuana? It’s not like I have a problem...hell, they’re making it legal in some states…and it chills me out so I don’t blow up at people.”

OARS: How might you reflect this statement?

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OARS: Summaries • Special form of reflective listening • Structure:

• Indicate you’re about to summarize • Be selective • Note ambivalence & attend to change

statements • Be concise! • End with invitation

• Use to change directions or ask a key question

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1. Engaging: listening to understand the dilemma using OARS

2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice

3. Evoking: selective eliciting, selective responding, selective summaries toward change talk

4. Planning: moving to a change plan and obtaining commitment

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Four MI Processes

When is it MI? Processes 1, 2, and 3 are necessary for it to be MI

Goals

• Agenda setting – identifying a strategic focus

• Exploring ambivalence – deepening understanding of motivation, listening for change talk

• Offering and sharing information

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Process II - Focusing

• “What would you like to make sure we take care of today? • “What else?” • “What are your concerns?” • “What is most important for us to work on?” • “What would you like to change?” • “Where would you like to start?”

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Open-Ended Questions: Finding a Shared Agenda

• “If you were to change something about your [problem behavior] what might that be? “

• “What might that look like?” • “How would you go about it?”

Hypothetical Questions: Finding a Shared Agenda

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• ELICIT readiness and interest • “What do you know about the effects of …” • “What concerns do you have about…?”

• PROVIDE clear information or feedback • “What happens to some people is that…” • “One effective way to communicate with your kids is…” • “As your doctor/counselor/nurse, I strongly urge you to…”

• ELICIT the interpretation or reaction • “What do you think?” • “How do you think you might…?”

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Finding a Shared Agenda (Focusing): Elicit, Provide, Elicit

1. Engaging: listening to understand the dilemma using OARS

2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice

3. Evoking: selective eliciting, selective responding, selective summaries toward change talk

4. Planning: moving to a change plan and obtaining commitment

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Four MI Processes

When is it MI? Processes 1, 2, and 3 are necessary for it to be MI

Lisa Merlo: Effective Physician and Smoking Cessation https://www.youtube.com/watch?v=URiKA7CKtfc&t=316s :00 – 5:14 Consider listening for OARS from provider and/or Change talk and Sustain talk from client 50

In Summary • A large body of literature shows that MI can directly

impact client outcomes, especially as it relates to substance abuse

• Before you can make a plan for behavior change and even before you can successfully talk about an individual’s desire, ability, reasons, and need to change a behavior, you must have developed rapport (Engaging) and collaboratively identified WHAT the behavior is that you will be talking about potentially changing (Focusing)

• Only then are you BOTH ready to talk about the veteran’s desire, ability, reasons, and need for the behavior change and ultimately to engage in planning or finding a solution. 51

What can I do even better yet? • Feedback- Keep doing, do more of, do less of, stop

doing, consider doing • What would make your learning experience even better

yet? What can you do even better yet? • What do you plan to work on over the next month? • How might you use engaging with OARS and focusing

when discussing behavior change with your veterans? • How will you know that you succeeded?

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Wrap Up and Planning

Where will you go from here?

• Learning MI takes practice and feedback. • Starting with a few skills is usually more

effective than trying to use every skill you’ve learned at once.

• Follow-up call next month to address Processes 3 and 4, Evoking Change Talk and Planning

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• Motivational Interviewing: Preparing People for Change (2012). Miller and Rollnick, 3rd edition, Guilford Press

• Motivational Interviewing in Health Care (2007). Rollnick, Miller and Butler, Guilford Press

• Motivational Interviewing in the Treatment of Psychological Problems (2007). Ed: Arkowitz, Westra, Miller and Rollnick, Guilford Press

• http://www.motivationalinterviewing.org: bibliography; training resources

• Motivational Interviewing for Leadership: MI-LEAD (2017). Wilcox, Kersh, and Jenkins, 1st edition, Gray Beach Publishing

Contact: • Elizabeth Jenkins, PhD, Clinical Psychologist, ext 4963

Sources of Information on MI

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